Nokea
A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first?
- A. Prepare to administer sodium polystyrene sulfonate (Kayexalate) 15 g by mouth
- B. Provide a client healthy, low potassium diet
- C. Prepare to administer dextrose 20% and 10 units of regular insulin IV push
- D. Prepare the client for hemodialysis treatment
Correct Answer: C
Rationale: A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the serum potassium level. Insulin with dextrose enhances potassium movement into cells, reducing serum levels quickly. This is the fastest and most immediate intervention.
You may also like to solve these questions
A client at risk for developing hyperkalemia states, 'I love fruit and usually eat it every day, but now I can't because of my high potassium level.' How should the nurse respond?
- A. Potatoes and avocados can be substituted for fruit
- B. Fruit is universally high in potassium
- C. Berries, cherries, apples, and peaches are low in potassium
- D. You are correct. Fruit is very high in potassium
Correct Answer: C
Rationale: Not all fruits are potassium-rich. Berries, cherries, apples, and peaches are relatively low in potassium and can be included in the diet of a client at risk for hyperkalemia.
A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
- A. Bowel sounds
- B. Depth of respirations
- C. Grip strength
- D. Electrocardiography
Correct Answer: B
Rationale: A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the client's respiratory status first to ensure respirations are sufficient.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?
- A. Client receiving 5% dextrose in water (D5W) intravenously and is NPO
- B. A 34-year-old with an infection who is prescribed a sulfonamide antibiotic
- C. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
- D. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)
Correct Answer: A
Rationale: Clients receiving 5% dextrose in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia.
A nurse teaches a client who is at risk for mild hyponatremia. Which statement should the nurse include in this client's teaching?
- A. Weigh yourself every morning and every night
- B. A 3-year-old with a client who is prescribed a sulfonamide antibiotic
- C. Read food labels to determine sodium content
- D. Bake and grill to treat rather than frying it
Correct Answer: C
Rationale: Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate sodium content helps manage sodium intake to prevent hyponatremia. The method of cooking does not significantly alter sodium content unless high-sodium ingredients are added.
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)
- A. Urine output of 250 mL in 8 hours
- B. Serum potassium level of 5.8 mEq/L
- C. Blood pressure of 88/54 mm Hg
- D. Decreased urine specific gravity
- E. Increased urine specific gravity
Correct Answer: B,E
Rationale: Aldosterone inhibition increases potassium retention and water excretion, leading to hyperkalemia (elevated serum potassium) and increased urine specific gravity due to concentrated urine.